Health Plan of San Joaquin/Mountain Valley Health Plan · 8 hours ago
Claims Adjustment and Dispute Specialist
French Camp, CA
Full-time
Remote
Mid Level
3+ years exp
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Responsibilities
Reviews claims, appeals, refunds, PLOGS, reinsurance cases, correspondence and other documents.
Identifies errors and analyzes to determine cause.
Documents findings and sends back for correction and adjudication.
Provides feedback and/or compiles and submits reports in a timely and accurate manner.
Monitors potential large loss claims; requests reimbursement for payments as required.
Collaborates with internal and external customers to answer questions, request information; sends required correspondence.
Qualification
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Required
In-depth knowledge of regulations governing Medi-Cal as they relate to claims processing.
In-depth knowledge of procedure coding and medical terminology, and their application in claims.
In-depth knowledge of general medical policy benefits and exclusions.
In-depth knowledge of industry standard payment practices.
In-depth knowledge of HPSJ systems as they relate to claims processing.
Basic leadership skills, including but not limited to the ability to influence without authority and motivate others.
Demonstrates a commitment to HPSJ’s strategy, vision, mission and values.
Strong interpersonal skills, including the ability to establish and maintain effective working relationships with individuals at all levels inside and outside of HPSJ.
Strong oral and written communication skills, with the ability to communicate professionally, effectively explain complex information, and document according to standards.
Ability to work independently and as part of a team.
Strong knowledge of basic data analysis and communication/reporting tools and techniques, with ability to perform analysis and resolve problems of moderate complexity, and recognize and act on trends.
Strong organizational skills, with the ability to prioritize and complete a wide variety of tasks.
Basic arithmetic skills.
Basic skills in Windows, Excel, Word and Outlook.
Ability to handle confidential information with appropriate discretion.
Ability to speak and be understood in English.
High school diploma or general education degree;
At least three years as an Analyst II or equivalent.
None
Preferred
Basic knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them.
Basic knowledge of the reinsurance process.
Associate’s Degree
Claims auditing experience.
Certified in medical coding or auditing
Benefits
Robust and affordable health/dental/vision (90% paid medical for employees and 100% paid dental/vision for employees)
Generous paid time off (starting at 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
Two flexible spending accounts (FSAs)
Employer-Paid Term Life and AD&D Insurance
Employer-Paid Disability Insurance
Employer-Paid Life Assistance Program
Health Advocacy
Supplemental medical, legal, identity theft protection
Access to exclusive discount mall
Education and training reimbursement in addition to employer-paid elective learning courses.
Company
Health Plan of San Joaquin/Mountain Valley Health Plan
Health Plan of San Joaquin/Mountain Valley Health Plan (not-for-profit health plan) is the leading Medi-Cal managed care provider in San Joaquin in Stanislaus Counties, now serving Medi-Cal members in Alpine in El Dorado Counties.
501-1,000 employees
Funding
Current Stage
Late StageLeadership Team
Michael Schrader
CEO
Company data provided by crunchbase
